Children's home run by Thoughts of Others Limited in Birmingham

Inspection report children‟s home: SC484716 1 SC484716 Registered provider: Thoughts of Others Limited Full inspection Inspected under the social care common inspection framework

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Information about this children’s home

This children‟s home is registered to provide care and accommodation for up to six young people who have emotional and/or behavioural difficulties. The organisation operates a school nearby and can provide therapeutic services.

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Overall experiences and progress of

children and young people, taking into account

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inadequate

How well children and young people are helped and protected inadequate

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inadequate

The effectiveness of leaders and managers inadequate

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inadequate

There are serious and/or widespread failures that mean children and young people are not protected or their welfare is not promoted or safeguarded.

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inadequate

Overall judgement at last inspection: inadequate

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Enforcement action since last inspection:

This children‟s home was judged inadequate at the full inspection on 5 and 6 July 2017. Following the inspection, Ofsted issued 18 compliance notices. A monitoring visit took place on 17 August 2017. The registered person had taken some action to meet six of the 18 compliance notices. Ofsted then issued 12 compliance notices again for the unmet regulations. Inspection report children‟s home: SC484716 2

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Key findings from this inspection

This children‟s home is inadequate because:

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Key findings from this inspection

 There has been no registered manager at the home for over 12 months.  The registered person has not met four of the 12 compliance requirements.  The pace of improvement since the home was judged inadequate in July 2017 remains slow.  The responsible individual has not supervised the manager of the home.  Leaders and managers miss opportunities to learn lessons from experience.  External independent scrutiny is weak.  There is poor risk management of young people who may go missing.  Managers lack a focus on safeguarding during supervision.  Young people do not experience continuity and consistency of care.  Records about young people are unreliable.

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Key findings from this inspection

 Young people make good educational progress through regular attendance at the organisation‟s school.  Placing social workers told inspectors that they are positive about how the service supports their young people.  Young people have prompt access to the organisation‟s range of therapies that help young people to receive emotional help at the point of need.

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Inspection date Inspection type Inspection judgement

05/07/2017 Full Inadequate 09/11/2016 Full Requires improvement 26/07/2016 Full Inadequate 25/02/2016 Interim Declined in effectiveness Inspection report children‟s home: SC484716 3

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Statutory requirements

This section sets out the actions that the registered person(s) must take to meet the Care Standards Act 2000, Children‟s Homes (England) Regulations 2015 and the „Guide to the children‟s homes regulations including the quality standards‟. The registered person(s) must comply within the given timescales.

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Requirement Due date

The protection of children standard is that children are protected from harm and enabled to keep themselves safe. In particular, the standard in paragraph (1) requires the registered person to ensure that staff assess whether each child is at risk of harm, taking into account information in the child‟s relevant plans, and, if necessary, make arrangements to reduce the risk of any harm to the child. (Regulation 12 (1)(2)(a)(i)) 03/12/2017

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Requirement Due date

The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children‟s home that helps children aspire to fulfil their potential and promotes their welfare. In particular, the standard in paragraph (1) requires the registered person to ensure that the home‟s workforce provides continuity of care to each child. (Regulation 13 (2)(e))* 03/12/2017

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Requirement Due date

The leadership and management standard is that the registered person enables, inspires and leads a culture in relation to the children‟s home that helps children aspire to fulfil their potential and promotes their welfare. In particular, the standard in paragraph (1) requires the registered person to use monitoring and review systems to make continuous improvements in the quality of care provided in the home. (Regulation 13 (2)(h))* 03/12/2017

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Requirement Due date

The care planning standard is that children have a positive experience of arriving at or moving on from the home. In particular, the standard in paragraph (1) requires the registered person to ensure that arrangements are in place to ensure the effective induction of each child into the home. (Regulation 14 (1)(b) and (2)(b)(i))* 03/12/2017

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Requirement Due date

The registered provider must ensure that the responsible individual satisfies the requirements in paragraph (5) (a) to (c) and has the capacity, experience and skills to supervise the management of the home, or the homes, in respect of which 03/12/2017 Inspection report children‟s home: SC484716 4 the responsible individual is nominated. (Regulation 26 (7)(a)(b)) In particular, that he does supervise the management of the home and is accountable for improvement. The registered person must ensure that the employment of any person on a temporary basis at the children‟s home does not prevent children from receiving such continuity of care as is reasonable to meet their needs. (Regulation 31 (1)) 03/12/2017

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Requirement Due date

The registered person must ensure that all employees receive practice-related supervision by a person with appropriate experience. (Regulation 33 (4)(b))* 03/12/2017

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Requirement Due date

The registered person must maintain records (“case records”) for each child which include the information and documents listed in Schedule 3 in relation to each child, are kept up to date and are signed and dated by the author of each entry. (Regulation 36 (1)(a)(b)(c)) In particular, the responsible individual must ensure that electronic and hard copy records and documents created by staff are evidentially reliable in terms of the author, date of creation and any updates. 03/12/2017

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Requirement Due date

* These requirements are subject to a compliance notice.

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Recommendations

 Identify and provide appropriate opportunities for children to develop themselves in accordance with their wishes and feelings and as part of the home‟s plan for their care. Each child‟s talents and interests should be understood and nurtured, with children selecting activities based on their personal preferences and abilities, so far as is reasonable. Staff should also support children to try activities that are „new‟ for them, where appropriate, such as other clubs, volunteering and leisure activities that will promote their independence. Specifically, promote positive independent friendships, enjoyment and fun. („Guide to the children‟s homes regulations including the quality standards‟, page 31, paragraph 6.4)  The registered person should actively seek independent scrutiny of the home and make best use of information from independent and internal monitoring (including under Regulations 44 and 45) to ensure continuous improvement. They

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Recommendations

should be skilled in anticipating difficulties and reviewing incidents, such as learning from disruptions and placement breakdowns. They are responsible for proactively implementing lessons learned and sustaining good practice. („Guide to the children‟s homes regulations including the quality standards‟, page 55, paragraph 10.24)

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Inspection judgements

Inspection report children‟s home: SC484716 5

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Overall experiences and progress of children and young people: inadequate

Since the last inspection, there have been some improvements in young people‟s experience. These changes are very recent and improvements have not yet been sustained over time.

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Overall experiences and progress of children and young people: inadequate

Young people‟s overall progress continues to be jeopardised by weaknesses in safeguarding arrangements and in gaps in leadership and management.

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Overall experiences and progress of children and young people: inadequate

Young people still do not have consistency in the number of staff who care for them. There is still a reliance on temporary staff in supporting young people. This continuing situation compromises young people making meaningful relationships with familiar staff. For example, young people have told the manager that they want more time with the staff they trust. One young person escalated his view about wanting more time with his key worker as a complaint. The responsible individual has made positive assurances about this in a swift, informal response.

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Overall experiences and progress of children and young people: inadequate

One young person‟s in-house psychiatric assessment highlights the importance of having stability of staff by stating that this is the young person‟s last chance „at establishing good enough attachment relationships that he can internalise and take into his adult life‟. A placing social worker told inspectors that this young person felt „left out and isolated‟ because staff tend to focus more on „challenging young people‟ in placement and just leave him to get on with things.

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Overall experiences and progress of children and young people: inadequate

Young people told inspectors that the new manager is now listening and responding to their views. For example, they suggested a daily cooked communal breakfast to help them have a positive morning before school. The manager has regularly come in early to make sure that this has happened.

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Overall experiences and progress of children and young people: inadequate

Young people continue to do well in the organisation‟s school. Their regular attendance and tailored support are enabling young people to make good educational progress. This has helped young people to get their learning back on track and to gain qualifications they need for their future employment or higher education.

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Overall experiences and progress of children and young people: inadequate

The new manager, appointed in July 2017, is ensuring that young people are increasingly consulted. This is noticeable in their engagement in the decor of their bedrooms and the lounges.

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Overall experiences and progress of children and young people: inadequate

Young people live in a calmer home. Three young people currently live at the home. The new manager sets the tone of a more nurturing, less restrictive home, where young people can be open about their feelings. Direct work, often completed by the manager about significant issues, is now happening.

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Overall experiences and progress of children and young people: inadequate

The new manager is now building relationships with the local police and with placing social workers, successfully securing a long overdue local authority pathway plan for one young person. Placing authorities are positive about the care and security that their Inspection report children‟s home: SC484716 6 young people experience. One social worker told the inspector that her young person was „a lot more mature, their self-confidence has grown‟. Young people also recognise the positives of living at the home.

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Overall experiences and progress of children and young people: inadequate

Arrangements for the administration of medication have improved. Staff are better able to meet young people‟s health needs because they are now trained in understanding epilepsy. Some young people have regular therapeutic sessions with a psychologist, or independence training. Speech and language therapy and music therapy are also available. Prompt access to therapists helps young people to receive emotional support at the time of need.

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Overall experiences and progress of children and young people: inadequate

Staff help young people to keep in touch with the significant adults in their life, including ex-staff members and families who live far away. One young person has had a positive, planned, gradual move out to a new placement nearer to his family home. Another young person can now see a positive future, away from previous risks of gang involvement. Other young people are making plans or thinking about the next move for them, to foster care or to independent living.

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How well children and young people are helped and protected: inadequate

Staff, including the new manager, continue to fail to identify, understand or manage risk safely. There is an absence of forward thinking and planning to reduce the risk of harm. For example, a young person, with a significant history of going missing, went missing during the night when he was on holiday with one member of staff. Despite the known risk, no recording was made about how the risk would be managed during a period away. Therefore, there was no consideration of the location, or how a lone member of staff could safely manage a search, or respond if ill or after any accident. This decision to allow one member of staff to go on their own was not safe or wise.

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How well children and young people are helped and protected: inadequate

Leaders and managers have not learned from previous incidents where young people have been placed at risk of harm. They have not used this knowledge to inform more recent risk assessments to help improve protection. Practice to review significant incidents when young people have gone missing is inadequate. For example, neither the manager, her supervisor nor the responsible individual reviewed the most recent incident of going missing. Basic risk assessments and children‟s profiles are now shared with the police and placing authorities.

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How well children and young people are helped and protected: inadequate

This poor safeguarding culture and the lack of effective risk management and review have been a weakness for over 12 months, and seen at the last three full inspections.

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How well children and young people are helped and protected: inadequate

Frequent changes in staffing mean that staff do not have time to keep up to date with recording and do not routinely meet as a group to share information about risk. Some risk assessments appear to be very similar to those of young people who are living in another of the registered provider‟s homes. They appear to be a standardised „cut and paste‟ format rather than reflecting individual needs. They indicate a blanket approach to risk reduction through security measures and constant staff supervision. Not all young people are supported to take appropriate risks as part of developing life skills in Inspection report children‟s home: SC484716 7 readiness for adulthood.

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How well children and young people are helped and protected: inadequate

The new manager has begun to make some improvements. Staff now implement the organisation‟s behaviour management policy. Young people have not been restrained and the manager has implemented a new restorative approach in an effort to reduce sanctions. Young people are no longer restricted from communal areas of the home as a sanction. Staff are recruited satisfactorily.

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How well children and young people are helped and protected: inadequate

Despite these improvements, both internal and external monitoring, and the supervision of the manager, all omit crucial information about safeguarding incidents. This includes physical restraint and when young people go missing from care. This is a systemic weakness given the history of the home.

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The effectiveness of leaders and managers: inadequate

The pace of improvement is far too slow. Although the registered person has met eight of the 12 reissued compliance notices, four remain unmet. Critical areas, which remain unmet and which are still inadequate, include the continuity of care, supervision, monitoring and review of the quality of care and placement endings.

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The effectiveness of leaders and managers: inadequate

This home has been without a registered manager since September 2016. The current manager was appointed in July 2017 and has yet to submit an application to register with Ofsted.

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The effectiveness of leaders and managers: inadequate

Managerial monitoring and review are ineffective. Leaders and managers have relied on the new appointed manager to drive improvement at the home. The responsible individual has neither had a role in creating or reviewing the action plan, which was written to respond to the 12 failed compliance notices, nor any subsequent development plan. The registered person has not shared the action plan with Ofsted as required.

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The effectiveness of leaders and managers: inadequate

The responsible individual has not been formally involved in ensuring the quality of care at the home since the last compliance monitoring visit on 17 August 2017. The responsible individual neither supervises the management of the home nor the manager. Consequently, there is not a chain of accountability for decision-making that links the responsible individual with the manager. The responsible individual told inspectors that he looked at a few pages of the manager‟s first monthly monitoring report but did not notice omissions in this document, such as the lack of monitoring of restraint records and incidents of going missing from care. The registered person does not monitor and review children‟s safety and progress. This means that he does not always understand young people‟s experiences.

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The effectiveness of leaders and managers: inadequate

The registered person did not carry out an effective review of placement endings. As a result, the registered person did not identify any learning to promote young people‟s placement stability in future placements and reduce the chances of placements ending early.

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The effectiveness of leaders and managers: inadequate

Staff supervision does not routinely include safeguarding or child protection issues. For Inspection report children‟s home: SC484716 8 example, the supervision of the manager by the organisation‟s placements manager omitted discussion about a significant safeguarding incident at the home.

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The effectiveness of leaders and managers: inadequate

The registered person has not made any analysis of the staffing model in relation to continuity of care. The manager‟s action plan and development plan do not detail any actions to improve continuity, consistency and reduce staff turnover.

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The effectiveness of leaders and managers: inadequate

Too many members of staff continue to work with young people. In the last 31 days, 42 different members of staff have worked with young people. This has meant that pool staff are frequently used instead of dedicated core staff team members.

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The effectiveness of leaders and managers: inadequate

Since March 2017, 50% of the staff have left and of these, 25% were dismissed. The responsible individual has not drawn any conclusions to determine if staff turnover is too high or to the impact that this has on young people. He has not attempted to understand or address this negative trend.

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The effectiveness of leaders and managers: inadequate

The majority of staff working with young people are not supervised by the manager and are not part of staff teams. As a result, staff do not have a regular opportunity to meet together to improve the continuity of care that they deliver to young people.

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The effectiveness of leaders and managers: inadequate

Independent scrutiny is ineffective. The newly appointed independent visitor visited the home in August and September. However, only one of the reports has been sent to Ofsted. Despite known incidents of safeguarding and going missing, neither of the reports identify these. The responsible individual did not identify this weakness. The home still has broken curtain poles and tracks, dirty rooms and broken furniture. The manager said that she is working with staff on their cleaning rigour.

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The effectiveness of leaders and managers: inadequate

The registered person‟s system for document security and authentication is poor. For example, the responsible individual does not know whether hard copy documents he gave to the inspectors as evidence were reliable. The date of document creation and authorship could not be relied upon.

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The effectiveness of leaders and managers: inadequate

Staff training has improved and the core staff team members have now received the training. For example, staff have received awareness training in understanding epilepsy. However, only six of the core staff team members have an appropriate qualification in working with children, another six core staff team members are enrolled to complete this. The frequency of supervision has achieved the organisation‟s target only once. The new manager made sure that all of the core staff team members and one teacher who works as a relief member of staff have had at least one supervision session in the last two months, as required.

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The effectiveness of leaders and managers: inadequate

Placing local authorities appreciate that the staff provide security for their „hard to place‟ young people. The manager has made links with the local police to avoid working in isolation.

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The effectiveness of leaders and managers: inadequate

The statement of purpose has been revised and no longer states that the home employs a registered nurse. Staff have appropriate overnight accommodation because, with fewer Inspection report children‟s home: SC484716 9 young people, they now sleep in two of the vacant bedrooms.

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The effectiveness of leaders and managers: inadequate

The responsible individual has applied for retrospective planning permission to regularise the unauthorised extension.

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The effectiveness of leaders and managers: inadequate

The leaders and managers continue to demonstrate limited understanding of the home‟s strengths or weaknesses. They have not demonstrated that they have the capacity to identify and rectify shortfalls or make effective improvement plans.

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Information about this inspection

Inspectors have looked closely at the experiences and progress of children and young people. Inspectors considered the quality of work and the differences made to the lives of children and young people. They watched how professional staff work with children and young people and each other and discussed the effectiveness of help and care provided. Wherever possible, they talked to children and young people and their families. In addition, the inspectors have tried to understand what the children‟s home knows about how well it is performing, how well it is doing and what difference it is making for the children and young people whom it is trying to help, protect and look after.

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Information about this inspection

Using the „Social care common inspection framework‟, this inspection was carried out under the Care Standards Act 2000 to assess the effectiveness of the service, how it meets the core functions of the service as set out in legislation, and to consider how well it complies with the Children‟s Homes (England) Regulations 2015 and the „Guide to the children‟s homes regulations including the quality standards‟. Inspection report children‟s home: SC484716 10

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Children’s home details

Registered provider: Thoughts of Others Limited

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Children’s home details

Registered provider address: Thoughts of Others, 99 College Road, Sutton Coldfield, West Midlands B73 5DL

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Inspectors

Christy Wannop: social care inspector Dawn Bennett: social care inspector Inspection report children‟s home: SC484716 11 achieve excellence in the care of children and young people, and in education and skills for learners of all ages. It regulates and inspects childcare and children‟s social care, and inspects the Children and Family Court Advisory and Support Service (Cafcass), schools, colleges, initial teacher training, further education and skills, adult and community learning, and education and training in prisons and other secure establishments. It assesses council children‟s services, and inspects services for looked after children, safeguarding and child protection.

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Inspectors

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Inspectors

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Inspectors

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